Mental Healthcare Bill 2013: The Politics of Silence that Eclipses Public Health Vision

Public health law advocates legislation as a key policy measure for realizing the equitable distribution of health as a public good. The Mental Healthcare Bill 2013 (MHB) was passed by the Rajya Sabha with 134 amendments on August 8, 2016. Subsequently, it is also passed by the Lok Sabha in the budget session of 2017. This is hailed as a promising new deal in mental health in India. While replacing the Mental Health Act 1987 and decriminalising attempt to suicide, it provides for the ‘protection of the mentally ill person’ and for realizing ‘the right to affordable and accessible mental healthcare without discrimination’ (at the public health care institutions). The feasibility of achieving such a goal in the current political orientation to public health in India needs critical consideration.

The ‘eloquent’ silence: The MHB is silent on the most critical factors necessary for achieving these objectives which includes financing mechanism, primary healthcare (PHC) level arrangements and the provision of legal- remedial measures for the violations of rights of persons with mental illness (PMI). The socio-political contexts and the political orientation provide a better perspective to decipher the criticality of this silence.

Much before the euphoria of MHB peters out; there is a compelling need to put the act together for a comprehensive vision. The fragmented civil society lobbying for piecemeal legislations needs to realise that more laws will not accrue more rights and that only a well-functioning comprehensive PHC system can effectively address special healthcare needs including needs of PMIs.

India’s public expenditure currently is a dismal 1.2 percent of GDP, among the lowest in the world. The High Level Expert Group (HLEG) report commissioned by the erstwhile Planning Commission of India in 2011 diagnosed this factor as the root cause of the malaise resulting in further impoverishment of the populations. National Health Accounts (2013-14) have described the root of the malaise in the resource allocation terms. In common parlance the per capita expenditure on health care is Rs.3638 of which about, 72% (i.e. Rs.2596) is out of pocket expenditure (spent by patients) and only 28 (Rs.1,042) percent is the expenditure by the government. This is by far one of the lowest public spending on health care as even governments in Kenya, Zambia, Kyrgistan and Sri Lanka spend comparatively more than this. The Lancet (May 2016) has drawn attention to the abysmal state of health care system including mental health care infrastructure. The Parliamentary Standing Committee Report makes the central government responsible for the allocation of funds and casts an obligation on IRDA for making insurance accessible for PMIs. The MHB is totally silent on both these counts! Where is the money going to come from if the total allocation is not increased? Now that the GST Bill is passed, will the Centre pass the buck to the states as was done in the original draft?

The MHB glosses over the socio-psychological dimensions of mental health and only deals with it as a medical problem needing institutionalization. A range of psycho-social arrangements need to be put in place at the PHC level as therapeutic measures such as skilled as well as barefoot counselors, sensitized and trained PHC level health care providers, before the intervention of a psychiatrist is deemed necessary. TheLancet (December 2015) had indicated ‘an integrated national health-care system built around a strong public primary healthcare (PHC) system’ supported by the private and indigenous sectors’ as the architectural change that was required. A third feature that MHB is totally silent on is the remedies for the violations of the rights of PMI, and access to care without discrimination in the private healthcare sector.

Need: a comprehensive – integrated vision: The federal polity has resulted in virtually ‘passing the buck’ making public health the biggest casualty. To make both the centre and states accountable, a suitable constitutional amendment to make health care a concurrent subject might be necessary. Health being a state subject, there are over a thousand legislations relating to health care in various states of India. Instead India needs a comprehensive law to monitor the public health care, regulate the private care and to ensure patients’ rights. Political will both to raise the healthcare budget to 3.5% of the GDP to be able to deliver as well as to transform and re-orient medical education to make available quality human resource for the public health care sector is a sine qua non even for meeting the mental health care needs.

Much before the euphoria of MHB peters out; there is a compelling need to put the act together for a comprehensive vision. The fragmented civil society lobbying for piecemeal legislations needs to realise that more laws will not accrue more rights and that only a well-functioning comprehensive PHC system can effectively address special healthcare needs including needs of PMIs. Even as the private drugs and medical lobby is just waiting to make mental illness a new business with an already assured market of 70 million people, the citizens need to be well guarded against a myth that drugs and psychiatrists alone will usher in mental health in the country! A PHC vision based integrated psycho-social and community mental health approach supplemented by a well-equipped mental healthcare institutions at the district and state levels will go a long way in ensuring ‘the right to affordable and accessible mental healthcare without discrimination’.